Re-engineering systems has been particularly meaningful in preventing and treating heart attacks, says Dr. Manning, who represented SHM at a meeting of the Alliance for Cardiac Care Excellence (ACE), a CMS-based coalition that includes leaders from more than 30 healthcare organizations, and is working to ensure that all hospitalized cardiac patients regularly receive care consistent with nationally accepted standards.
11. Institute Multidisciplinary Rounds
Time constraints mean rounding with 10 people will necessarily be slower, says Dr. Alverson. In academic institutions where the hospitalist has the dual responsibility of teaching, this is especially time-consuming. Although there is an increasing emphasis that providers should participate at bedside rounds, and this is “clearly better from the patient’s perspective and, I would argue, better from the educational perspective,” says Dr. Alverson, it is “fairly bad from the getting-things-done-in-a-timely-fashion perspective. So it’s tough, and to a certain degree, in a practical world you have to pick and choose.”
When a nurse representative is there to respond to the question, “ ‘Why didn’t the kid get his formula? [and says] because he didn’t like the taste,’ that’s something that we might not pick up on,” says Dr. Alverson.
At NYU Medical Center, where Dr. Rauch works, formal rounds take place at least once a week (sometimes more), depending on volume, and they informally take place twice a day, every day.
“It works pretty well,” he says. “The nurses are a critically important part of teams; everybody recognizes that, and they are included in decisions.” Physicians put out the welcome mat for nurses even in casual circumstances. “Sometimes I am discussing things with the house staff [and] a nurse will pull up a chair and become part of the conversation. It’s a part of our culture.”
Although it is unusual to get a pharmacist to round with his team, says Dr. Alverson, a nearby pharmacy school sends students to join rounds, providing what might otherwise be a missing element of education.
12. Avoid Miscommunication
A number of the hospitalists interviewed were asked what they considered to be the top two or three communication points for hospitalists. Verbal orders, clarifying with read-backs, clear handwriting, and order sets were named frequently. In academic settings, says one hospitalist, instructors should be careful to make sure that residents, interns, and medical students understand what you’re saying and why you’re saying it. Good communication with the family was also cited as crucial.
“The most challenging issue is communicating at all,” says Dr. Rauch, who is also an associate professor of pediatrics at the NYU School of Medicine. Although he was the only one to phrase it this way, it is probably not a unique view. “In a large, old, academic medical institution, there are a lot of hierarchical issues that [impede] rapidly responding to [patients’] needs.” Unfortunately, it may mean communicating up one authorization pathway and down another. “And you can see the layers of time and the game of telephone as the concerns go around,” he says. “We’ve tried to break that down so the people who are on site can speak to someone who can make a decision.”
Along with that, he says, it is important from the outset to make it very clear who makes the decision. “For example, when the patient is a child getting neurosurgery because they have a seizure disorder and they also are developmentally delayed and they have medical issues, you now have at least three services involved with managing the child,” says Dr. Rauch. When three people are making decisions, he points out, no decision gets made. “You really have to decide when that child comes in who is going to call the shots for what issue. It’s usually the hospitalist who brings it up, and when it works, it works well.”